Migration, Illness and Healthcare

Jenny Altschuler

• Publisher: Bloomsbury Academic
• Year: 2016
• Print ISBN:
  9781137378507
• eBook ISBN:
  9781350311237
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

Forces such as political conflict, globalisation and the growth of the internet, offering news of life elsewhere, mean levels of migration are higher now than at any other time in history. Despite the signing of a number of legally binding international treaties that seek to guarantee health care for migrants, there is still a considerable gap between government commitments and the reality of everyday life. As levels of migration continue to increase, it is essential for health care professionals to consider the differing needs of migrants in order to provide them with quality care.

Informed by systemic theory, and drawing on the author's extensive clinical – as well as personal – experience, this timely book explores the limited existing information about migrants' health care experiences. Providing a comprehensive insight into a worldwide issue, this is an essential guide for health care students, professionals and policy makers.

1

INTRODUCTION

Attending to the situation of the migrant at times of illness and death is to open ourselves to the coming together of two of the most radical thresholds of bodily estrangement and vulnerability: the movement across territories and from life to death. (Gunaratnam, 2013, p. 2)

The phenomenon of international migration is not new: migrations have occurred throughout human history, beginning with the movements of the first human groups from origins in East Africa to their current location in the world. However, the forces of globalization, economics, political conflict and growth of the Internet and social networks offering news of life elsewhere mean more people are on the move now than at any other time in history. In 2013, the International Organization for Migration estimated there were 232 million international migrants¹ worldwide, with nearly 50% living in the more developed countries of the world (IOM, 2013). This is predicted to rise to 405 million by 2050.

This pattern is reflected in Britain as well: in 2014 approximately 12.5% of the population was born abroad, compared with 8% in 2001. The net long-term migration to the UK was estimated to be 260,000 for the year ending June 2014, with immigration of people from the EU countries increasing by 45,000, and non-EU by 30,000. Until recently, most migrants were assumed to be adult men. However, as reflected in the UN International Migration Report, 48% of all migrants in 2013 were women and 15% were under the age of 20.

For much of the twentieth century, the numbers migrating to and from the UK were roughly in balance, and from the 1960s to the early 1990s the number of emigrants was often greater than the number of immigrants. Over the last two decades, both immigration and emigration have increased to historically high levels, with immigration exceeding emigration by more than 100,000 every year since 1998. More than 13 million of the UK population (20.3%) were either foreign national (7.8%) or foreign-born (12.5%) on 1 January 2014. In 2014, 13% of people migrating to the UK were British nationals, 32% were nationals of other EU countries and 45% were nationals of non-EU countries. This means just under half of migrants entering the UK in 2014 were subject to immigration control. The UK’s migrant population is concentrated in London. Around 37% of people living in the UK who were born abroad live in the capital city (Hawkins, 2015).

Experiences of migration vary considerably, influenced for example, by whether the decision was chosen or forced, the country one leaves and reception in the country to which one moves (Falicov, 2013; Fortier, 2002). Similarly, experiences of illness vary, influenced by such factors as the particular nature of the condition in question, the treatment available, access to practical and emotional support, and prior experiences of loss (Rolland, 1994; Altschuler, 2011). Nonetheless, even if one is able to transcend the disruption these experiences present to oneself and relationships with others, both forms of experience will be accompanied by some sense of loss and disarray, questions about bodies and embodiment, identity, memory, the remaking of memory, risk and resilience.

The speed of contemporary migrations, the numbers involved and the fact that they relate to areas with distinct disease profiles pose complex challenges to migrants, their non-migrant kin,² and the health care systems of their countries of origin/migration³ and destination/ settlement.⁴ Despite the importance of migrant labour to many sectors, including health and social services where migrants are needed to fill highly skilled as well as the low-skilled positions (such as domestic care for sick and elderly people), the policies and regulations of the UK and most EU countries are becoming less rather than more accommodating of migrants.

Studies of the so-called ‘health migrant effect’ suggest that those who leave tend to be the healthier, stronger and more resilient members of their society and are relatively healthy compared with the non-migrant population of the country to which they move (McDonald and Kennedy, 2004; Razum, Zeeb and Rohrmann, 2000). This is not the case for others, particularly refugees and asylum seekers. In many situations, poverty and language barriers mean it is difficult to find employment: as a result people accept more hazardous work and are therefore more vulnerable to injury and other occupational health hazards (Gushulak, Pace and Weekers, 2010; Jayaweera, 2014; Rechel et al., 2013).

Likewise, depending on the countries one moves to and from, migrants may be more vulnerable to certain communicable and non-communicable conditions. Migrants’ health is more likely to be compromised when the condition is stigmatized. For example, the UK has seen an increase in migrant-associated infectious disease, including HIV where the majority of people with heterosexually acquired HIV infection are from sub-Saharan Africa. While most health care services are well equipped to treat HIV/ AIDS from a medical perspective, fear, stigma and institutional barriers (including lack of cultural understanding and language barriers) mean African migrants tend to access HIV services at a later stage of disease than non-Africans, impacting on the quality of care they need and are able to receive (Burns et al., 2007).

Even where migrants are entitled to free health care, inadequate information regarding their rights to services presents barriers to accessing care and treatment, impacting on the possibilities of healing and survival (Hargreaves et al., 2008; Norredam, Mygind and Krasnick, 2006; Priebe et al., 2011). Sadly, it is often the more vulnerable migrants who are unable to access health care and do not understand their entitlements in the host country and in transit (Kirmayer et al., 2011).

The health risks for undocumented migrants are particularly high as they experience greatest problems in accessing health services and in many countries are expected to cover the full costs of medical treatment. Moreover, concerns about the possibility of being sent home mean that those who can afford this, use private services, where they are unlikely to be asked for any official form of identification, but this can mean being seen by unregistered health care workers (Dixon-Woods, Cavers and Agarwal, 2006; Woodward, Howard and Wolffers, 2013).

However, other than in screening of migrants to prevent the spread of communicable disease more prevalent elsewhere, concerns about the costs to the health care system and ‘brain drain’ of medical staff that resource-starved countries face, limited attention has been paid to the health implications of migration. The reluctance of many countries to sign the UN Convention on the Rights of Migrants (ratified in 2003) is indicative of a more widespread unwillingness to take account of the ethical as well as public health dimensions of migration (Jayaweera, 2014).

Indeed, in the midst of polarized debates about the risks and benefits of global capitalism and migration, there seems to be little space for thinking about ill, disabled and dying migrants and their families, about the pain, feelings of estrangement and loss that accrue over a lifetime, and the effects this can have on subsequent generations (Gunaratnam, 2013). Likewise, little thought is given to the challenges health care professionals face when language and cultural barriers mean it is difficult to communicate. Although this is starting to change, with the exception of health care professionals working in certain inner city settings, few have been trained to address the consequences of migration for experiences of illness, including the challenges of working with people who are extremely isolated and are struggling to adapt to a different social and geographic environment where constructions of illness, healing and health care are very different to what they were ‘back home’. Similarly, few feel equipped to address the particular challenges of refugees⁵ and asylum seekers,⁶ including the effects trauma can have on interactions with health care professionals and others in positions of authority (Hargreaves and Friedland, 2013; Kelly, Morrell and Sriskandarajah, 2005).

There has been a corresponding lack of thought about the positions of health care professionals who are themselves migrants: the challenges one faces in maintaining one’s sense of professional competence when qualifications are not recognized, the hurdles one needs to cross to qualify for registration, of having to adjust to a health care system where the paradigms of treatment, styles of communicating and approach to patient–doctor relationships are different to those of the country in which one trained and worked, and the complex feelings aroused by caring for others when one is unable to ‘be there’ to offer practical and emotional support for one’s own parents, siblings and children when they are ill, distressed or dying.

Growing concerns about the human rights and health care of migrants have led to the signing of a number of legally binding international trea-ties and resolutions, including the World Health Organization (WHO) ‘Resolution on the Health of Migrants’ (WHO, 2008) endorsing the commitment to develop and implement more effective methods for monitoring the health and health care of migrants, establishing practices, legal systems and policies sensitive to the positions of migrants, and reducing the level of discrimination which migrants from black and minority ethnic groups face. However, while most governments see health as an essential human right, there is still a considerable gap between stated resolutions like this and reality on the ground (Jayaweera, 2014; Rechel et al., 2013).

One explanation may lie in the fact that policies related to migration tend to be developed in ‘silos’ with different, often competing, goals, and pay little attention to health (Zimmerman, Kiss and Hossain, 2011). Other explanations are that the pace of worldwide migration might have out-stripped capacity to respond. Similarly the myth that most migrations are successful and desire to avoid facing the loss and fragmentation that so often accompany experiences of migration may have led to underplaying the more complex emotional and health challenges migrants and their families face.

However, it is also possible that this gap reflects a reluctance to engage with the position of those deemed to be outsiders. For example, one of the consequences of migrations from Africa, the Caribbean and the Mediterranean is that the incidence of certain forms of inherited conditions such as sickle-cell anaemia and thalassaemia in Britain has increased (Modell et al., 2007). Lack of experience in dealing with these conditions means that in some situations diagnostic, treatment and counselling services fall short of what is wanted and needed. Since these conditions are more prevalent amongst people from black and ethnic minority groups, studies indicating that people with sickle-cell anaemia do not always receive sufficient pain relief suggest that some of this shortfall relates to racism (Elander, Beach and Haywood, 2011; Nelson et al., 2013).

With these issues in mind, this book aims to extend understanding of what it means to be located and dislocated through migration and the ways in which these experiences inform and are informed by experiences of illness, offering recommendations for clinical practice. Particular attention is paid to migrations to and from the UK; however, the book draws on a wider body of academic and clinical studies and raises issues that apply to other forms of migration. Although it is intended to be for health care professionals and academics and researchers interested in the interface between migration, illness and health care, the concerns and questions discussed within this book are likely to be of interest to policy makers as well.

This opening chapter outlines the aims, anticipated readership and structure of the book, and the academic, professional and personal experience upon which the ideas, questions and recommendations presented here are based. Chapter 2 reviews what is currently known about migrancy and health. Chapter 3 discusses developments in theorizing and researching experiences of culture, language barriers and discrimination, and the implications for health care. Chapters 4 and 5 focus on illness and migration respectively, outlining the common threads and key concerns arising from the academic literature and clinical experiences.

The next three chapters draw these more generic discussions together by focusing on the intersection between migration and illness. Chapter 6 looks at the multiple ways in which experiences of migration, experiences of cultural diversity, language barriers and discrimination can inform responses to childhood and adult illness and death, and the reverse, with examples drawn from inpatient, palliative care, outpatient clinical work and supervision. In Chapter 7, Rachel Hopkins draws on her experience as a GP in discussing the challenges and more positive opportunities of working in a primary health care clinic where a high percentage of the population are first- or second-generation immigrants. Chapter 8 addresses an aspect of health care that has received little academic or clinical attention: the migration of health care professionals, including implications for the health care services of the countries they leave and move to, as well as the professional and more personal dilemmas they and their colleagues face. Statistics produced by the Health and Social Care Information Centre indicate that in 2015, 14% of clinical staff working for the NHS and in community health services were foreign nationals and/or trained abroad, in other EEA⁷ countries or so-called Third World countries, increasing to 26% for doctors and 39% for doctors on the specialist register (Health and Social Care Information Centre, 2016). As such, this chapter is likely to resonate with your experience as health care professionals, or the experience of your colleagues. The concluding chapter draws these themes together in presenting recommendations for the future.

Informed by systemic theory, the book draws on the assumption that although many aspects of migration and illness are deeply personal, personal experiences affect and are affected by interactions with the people with whom we are most intimately connected, the discourses dominating the wider socio-economic and political context, as well as the practical realities of everyday life. It is also informed by the narrative-based idea that in order to make sense of experiences, we develop ‘stories’ about these experiences. However, as one story is unable to portray the full complexity of events, particular constructions of reality are privileged over others: consequently other stories or constructions of experience are possible, including less pathologizing constructions of reality (White and Epston, 1990). Emphasis is placed on separating the person from the problem: people are assumed to have skills, abilities, values, commitments, beliefs and competencies that can assist them in changing their relationship with the problems that influence their lives.

The ideas raised here draw on developments in theorizing and researching migration, illness, experiences of culture, racialization and other forms of discrimination. Although attention is paid to common threads of experience, emphasis is placed on the heterogeneity of experience, including the differences between migrations that are chosen or forced, differences related to the medical condition in question, to particular family dynamics, personal resources and genetics, as well as the broader contexts of people’s lives, including class, racialization, gender and sexual orientation.

In addition, the book draws on clinical and personal experience. One of the first times I realized what a profound effect migration can have on experiences of illness and health care was when, as a newly appointed family therapist working for a hospital-based psychosocial liaison team, I was asked to see Rani, a 14-year-old girl who had been sent from Pakistan to the UK for treatment shortly after the diagnosis of end-stage renal failure. The decision to seek treatment in the UK arose from her family’s concerns about the quality of care she could access in Pakistan. However, it was also informed by the fact that her father had been working in the UK for a number of years, and was living with cousins who could offer her and her father support over the course of her treatment. Although Rani’s mother applied to join her daughter, her application was refused until much later.

The medical team that referred Rani felt she was extremely withdrawn and thought she and her father were finding it particularly difficult coming to terms with how ill Rani was. Consequently much of our initial work focused on the illness. It was only after meeting her and her father several times that I was able to see that in the immediacy of a medical crisis, I and the rest of the renal team had overlooked the fact that Rani was not only having to come to terms with the diagnosis of renal failure, the need for dialysis and risks to her future health, she was having to do so in a context that was foreign to her, where she was unable to speak the language or turn to the person who had been her primary source of support until then: her mother. We had also overlooked the challenges her father was facing in assuming primary responsibility for aspects of parenting that had previously been part of his wife’s domain. I cannot speak for my colleagues, but looking back I suspect that this initial ‘blindness’ related to my position as a relatively recent migrant, to my desire to fit in and avoid drawing attention to my own position as an outsider by focusing on the personal and family disruptions that arise from experiences of migration.

The ideas raised in this book also draw on my subsequent work with immigrant parents facing life-limiting illness in an outpatient mental health clinic, in primary health care settings where a high proportion of the patients are first- and second-generation migrants and refugees and a drop-in service for destitute asylum seekers, many of whom are experiencing symptoms of post-traumatic stress disorder. They also draw on my supervision of medical and non-medical health care professionals working in a range of inpatient and outpatient services, and the experience of setting up and mentoring staff working with families affected by political conflict in Kosovo and in refugees camps in Northern Greece.

Over the course of this work, many professionals have expressed discomfort about situations where cultural and language barriers led to misunderstandings and difficulties in providing the collaborative care they see as best practice. Others have spoken about the value of being able to learn about other constructions of heal...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Acknowledgements
• 1. Introduction
• 2. Links between migrancy and health
• 3. Individual and family experiences of illness and death
• 4. Cultural diversity, language barriers and prejudice
• 5. Individual and family experiences of migration
• 6. Intersection between migration and illness
• 7. Working with migrant patients in general practice
• 8. International health care migration
• 9. Conclusion
• Notes
• References
• Index